Effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy / 中国修复重建外科杂志

Objective: To investigate the effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Methods: The clinical data of 21 patients with unilateral foot drop secondary to peroneal nerve palsy between October 2009 and September 2016 was retrospectively analyzed. There were 12 males and 9 females with an average age of 32.1 years (range, 23-47 years). The causes of peroneal nerve injury were iatrogenic injury in 7 cases, tibiofibular fractures combined with compartment syndrome in 5 cases, nerve exploration surgery after stab or cut injury in 3 cases, direct violence in 4 cases, and the fibular head fracture in 2 cases. The average time from injury to operation was 5.6 years (range, 2-8 years). There was 1 case of hallux valgus and 5 cases of toe flexion contracture. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, Foot and Ankle Ability Measure (FAAM) scores, range of motion (ROM), and dorsiflexion strength of ankle joint were used to evaluated the ankle function. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, and hindfoot alignment angle. Results: All incisions healed by first intention. All patients were followed up 18-42 months (mean, 30.2 months). The dorsiflexion strength of ankle joint recovered from grade 0 to grade 3-4 after operation. There was no patient with a postoperative flat foot deformity and claw toe during follow-up. There was no significant difference in Meary angle, calcaneal pitch angle, and hindfoot alignment angle between pre- and post-operation ( P>0.05). The AOFAS score, FAAM score, and ROM of dorsiflexion significantly improved at last follow-up when compared with preoperative values ( P<0.05); while there was no significant difference in ROM of plantar-flexion between pre- and post-operation ( t=4.239, P=0.158). There were significant differences in AOFAS score, FAAM score, and ROM of dorsiflexion between affected and healthy sides ( P<0.05); but no significant difference in ROM of plantar-flexion was found ( t=2.319, P=0.538). Conclusion: Tibialis posterior tendon transfer is an effective surgical option for foot drop secondary to peroneal nerve palsy. And no postoperative flat foot deformity occurred at short-term follow-up.

A Irreducible Ankle Fracture and Dislocation Due to Injured Tibialis Posterior Tendon Interposition: A Case Report / 대한족부족관절학회지

Fractures and fracture-dislocations of the ankle are caused by a variety of mechanisms. In addition to fractures, injuries of soft tissue, such as ligaments, tendons, nerves, and muscles may also occur. Among these, a tibialis posterior tendon injury is difficult to be identified due to swelling and pain at the fracture site. It is difficult to observe tibialis posterior tendon injury on a simple radiograph; it is usually found during surgery by accident. There are some studies regarding irreducible ankle fracture-dislocations due to interposition of the tibialis posterior tendon; however, to the best of our knowledge, there has not been any report about interposition of injured tibialis posterior tendon. Herein, we report a case of an irreducible fracture-dislocation of the ankle due to injured tibialis posterior tendon interposition that was observed intraoperatively, interrupting the reduction of ankle fracture-dislocation. We obtained satisfactory clinical result after reduction of the trapped tendon, fracture reduction, and internal fixation; therefore, we are willing to report this case with the consent of the patient. This study was conducted with an approval from the local Institutional Ethics Review Board.

Accuracy of Needle Placement in Cadavers: Non-Guided Versus Ultrasound-Guided

OBJECTIVE: To compare the accuracy rates of non-guided vs. ultrasound-guided needle placement in four lower limb muscles (tibialis posterior, peroneus longus, and short and long heads of the biceps femoris). METHODS: Two electromyographers examined the four muscles in each of eight lower limbs from four fresh frozen cadavers. Each electromyographer injected an assigned dye into each targeted muscle in a lower limb twice (once without guidance, another under ultrasound guidance). Therefore, four injections were done in each muscle of one lower limb. All injections were performed by two electromyographers using 18 gauge 1.5 inch or 24 gauge 2.4 inch needles to place 0.5 mL of colored acryl solution into the target muscles. The third person was blinded to the injection technique and dissected the lower limbs and determined injection accuracy. RESULTS: A 71.9% accuracy rate was achieved by blind needle placement vs. 96.9% accuracy with ultrasound-guided needle placement (p=0.001). Blind needle placement accuracy ranged from 50% to 93.8%. CONCLUSION: Ultrasound guidance produced superior accuracy compared with that of blind needle placement in most muscles. Clinicians should consider ultrasound guidance to optimize needle placement in these muscles, particularly the tibialis posterior.

Failure of Reduction for Ankle Fracture-Dislocation Caused by Tibialis Posterior Tendon Interposition: A Case Report / 대한족부족관절학회지

Fracture and fracture-dislocation of the ankle may be caused by a variety of mechanisms. In addition to the fracture, injury of soft tissue such as ligaments, tendons, nerves, and muscles may occur. Among these, tibialis posterior tendon injury is difficult to identify due to swelling and pain at the fracture site. There is no clear finding in radiological examination, therefore, it is found during surgery. In this case, irreducible fracture-dislocation of the ankle due to tibialis posterior tendon interposition was observed after the primary operation. The authors obtained satisfactory results in performance of a secondary operation assisted with arthroscopy.

Sonographic Measurement of the Tibialis Posterior Tendon Diameters and Cross Sectional Area in Normal Korean Adults

OBJECTIVE: To provide normal reference values of the sonographic diameters and cross sectional area (CSA) of the posterior tibialis tendon (PTT) in Korean adults for early diagnosis and treatment of PTT dysfunction. METHOD: 240 feet from 120 healthy volunteers (63 males; 57 females, mean age: 36.40+/-11.37) were included in this study. Those with a previous history of surgery or trauma to the lower extremities and systemic disease, such as, hypertension, diabetes, or rheumatoid arthritis were excluded. PTT was examined through ultrasonograhy with the patient placed in the prone oblique position, with the knee extended, and ankle dorsiflexed to neutral angle. We evaluated the anterioposterior (AP) and transverse diameter and CSA of the PTT along the line that connected from the posteroinferior angle of the medial malleolus to the heel. RESULTS: The AP diameter of PTT measured by sonography was 3.42+/-0.03 mm and the transverse diameter of the PTT was 9.20+/-0.08 mm. The CSA was 21.46+/-0.26 mm2. Differences in diameters and CSA related to sidedness, sex did not show statistical significance (p>0.05). There was weak linear relationship in AP and transverse diameter and CSA with weight, height, leg and foot length. CONCLUSION: The normal Korean reference values of the PTT diameter and CSA that we obtained from ultrasonography can be used as useful reference data in diagnosing early pathologic conditions of PTT dysfunction.

THE EFFECTS OF EXERCISE OF THE PERONEUS LONGUS AND TIBIALIS POSTERIOR MUSCLES ON HEEL RAISE / 体力科学

Objective: This study aimed to clarify changes in planter pressure at the 1, 2, 5 metatarsal head, and muscle activities resulting from exercise of the peroneus longus (PL) or tibialis posterior (TP) muscles. Method: Nine subjects (3 male, 6 female) were recruited. Before and after exercise, planter pressure at the metatarsal heads and the activities of PL, TP, tibialis anterior, and soleus muscles were recorded during heel raising using electromyography and a foot sensor. The first exercise was a maximal isometric contraction of the PL and peroneus brevis (PB). The second was contraction of the TP, and the third was of all three, the PL, PB, and TP. Result: The amount of planter pressure at the first metatarsal head increased after PL exercise. The standard deviation at the second metatarsal head decreased after PL and TP exercise, but showed no change after PL exercise. Conclusion: After PL and TP exercise, heel raises were possible with few perturbations at the metatarsal head. After PL exercise, the amount of planter pressure at the first metatarsal head increased, but there was no change in perturbations. The results show that it is necessary to consider the effect of short time exercise.

The relationship of tibialis posterior tendons to the navicular and accessory navicular bones.

The accessory navicular bone is a common and frequently unrecognized anomaly, but occasionally the source of pain over the instep of a flat footed person. Since the tibialis posterior tendons are attached to it and navicular bone, thus, the tendons of tibialis posterior were observed. A total of 388 feet (207 males and 181 females) were involved in this study. In each case, all tendons were symmetrical. There were 293 feet (75.5%) with two types of tendon attached to the navicualr bone; naked tendons were found in 188 feet (48.4%) and sesamoid cartilage or bones within the tendon wee found in 105 feet (27.1%). These two tendon types passed under the medical border of each foot. The tendons that were attached to accessory navicular bones were found in 95 feet (24.5%); as a separated bone, in 64 feet (16.5%) and as a prolongation inward (cornuate navicular), in 31 feet (8%). Among these tendons, the abnormal courses of tendons were found inward and upward displacement in parallel with the medial border of the feet. No significant difference was found according to the sex of these subjects (p = 0.254).